Top suspects behind shoulder and elbow pain
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GP Talk: Top causes behind shoulder and elbow pain
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Top suspects behind shoulder and elbow pain
- 1. Professor M. A. Imam MD, MSc (Orth)(Hons), D.SportMed, Ph.D., FRCS (Tr. and Orth.) Consultant Trauma and Upper Limb Surgeon, Rowley Bristow Orthopaedic Unit, Chertsey Professor and MD, Smart Health Academic Unit, University of East London, London, UK Email: info@surreytotalhealth.co.uk Info@TheArmDoc.co.uk Website: www.TheArmDoc.co.uk @MoAImam Shoulder and Elbow Pain
- 3. • 2 Books (three ongoing) • 7 Awards • 16 Book chapters • 76 Peer reviewed publications • 14 Ongoing studies • 155 Presentations • 1 PhD (Rotator Cuff tears) • 3 Chief Investigator of international trials • Founder of OrthoGlobe Collborative (OrthoGlobe.Org), FRCS Mentor Initiative (FRCSMentor.co.uk) and Global Surgical Surveys (Globalsurgicalsurveys.org). National Research Committee (British Elbow and Shoulder Society)
- 7. Very Common
- 12. Where is the pain?
- 13. Pain, how bad is it?
- 14. Trauma Yes No Instability Fracture Rotator cuff tear Impingement Recent Yes No Frozen Shoulder Impingement Arthritis Rotator Cuff pathology
- 15. Age Child/Adolescent Fracture Instability Trauma Yes No Tumour Infection Impingement Rotator cuff tears Instability Middle Age Elderly Age Cuff tears Arthritis
- 16. Pain in relation to movement Pain at Rest Frozen Shoulder Arthritis Infection Cancer Yes Impingement Rotator cuff tears Mid arc High arc AC Pathology
- 18. And One More Scapular Dyskinesis = Abnormal Scapular motion
- 20. ELBOW Pain
- 21. Lateral Medial Posterior Anterior General deep ¨ Post traumatic ¨ Post surgical ¨ Heterotopic ossification ¨ Arthritis ¨ Loose bodies ¨ Arthritis ¨ PLRI Postero Lateral Rotatory Instability
- 22. • Lateral • “Lateral sided elbow pain” ≠ tennis elbow • Medial • Medial epicondylitis • Ulnar Neuritis • Posterior • Hyperextension valgus overload • Posteromedial impingement • Anterior • Biceps pathology • General deep • Arthritis Pain
- 23. Lateral sided elbow pain ¨Lateral epicondylitis ¨Radial tunnel syndrome (PIN) ¨Cervical radiculopathy ¨Osteochondral radiocapitellar lesion ¨Posterolateral elbow plica ¨Posterolateral elbow instability Volume 16, Number 1, January 2008
- 24. Lateral Epicondylitis (Tennis elbow) • Clinical • Pain over the lateral aspect of the elbow • Power grip, forced extension • Point tender common extensor origin • Stiffness unusual Volume 16, Number 1, January 2008
- 25. Tendinosis • Pathology • Degenerative – NOT “itis” • Tendinosis ECRB J Bone Joint Surg Am. 2005;87:187-202
- 26. Lateral Epicondylitis (Tennis elbow) Treatment ú Non operative Relative rest Activity modification Counterforce bracing Physiotherapy Injection – What? ECSW ?????? ú Operative Volume 16, Number 1, January 2008
- 27. Lateral Epicondylitis (Tennis elbow) Physiotherapy Stretches Eccentric strengthening - lengthen How do ecentric exercises work Rheumatology (2008) 47 (10): 1444-1445 Bisset L, Beller E, Jull G, et al: Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: Randomised trial. BMJ; 2006;333:939
- 28. Lateral epicondylitis • Injections • Local anaesthetic and steroid • Hyaluronic acid • Botox • Blood • Platelet rich plasma • Mesenchymal Stem cells
- 29. • Injections • Local anaesthetic and steroid BMJ; 2006;333:939 Bisset L, Beller E, Jull G, et al: Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: Randomised trial.
- 30. Lateral epicondylitis • Injections • Local anaesthetic and steroid Lindenhovius A, Henket M, Gilligan BP, Lozano-Calderon S, Jupiter JB, Ring D. Injection of dexamethasone versus placebo for lateral elbow pain: a prospective, double-blind, randomized clinical trial. J Hand Surg Am. 2008 Jul-Aug;33(6):909-19. CONCLUSIONS: Corticosteroid injection did not affect the apparently self- limited course of lateral elbow pain.
- 31. • Short term benefit • Long term worse off Lancet. 2010 Nov 20;376(9754):1751-67
- 32. Lateral epicondylitis • Injections • Local anaesthetic and steroid • Hyaluronic acid • Botox
- 33. Lateral epicondylitis • Injections • Local anaesthetic and steroid • Hyaluronic acid • Botox • Blood American Journal of Physical Medicine & Rehabilitation; Volume 89(8), August 2010, pp 660-667
- 34. Lateral epicondylitis • Injections • Local anaesthetic and steroid • Hyaluronic acid • Botox • Blood • Platelet rich plasma - PRP Am J Sports Med 2010 38: 255
- 35. Lateral epicondylitis • Platelets • VEGF – Vascular endothelial growth factor • PDGF – Platelet derived growth factor • FGF – Fibroblast growth factor • TGF B – Transforming growth factor • EGF – Epithelial growth factor
- 36. Lateral epicondylitis • Injections • Local anaesthetic and steroid • Hyaluronic acid • Botox • Blood • Platelet rich plasma - PRP • Mesenchymal Stem cells
- 37. Operative Lateral epicondyle • Percutaneous • Open • Arthroscopic
- 38. Lateral epicondylitis • What I say/ do – • No magic bullet – Non operative 6 months • Physiotherapy • 5 – 10 minutes won’t do TENDINOSIS • Use counter force brace • Reassure – Hurts no long term harm • Injection • No steroids • Try PRP (£) • Percutaneous release ( x - ray/ MRI - a scope) • www.TheArmDoc.co.uk • Patient information
- 39. JBJS-B VOL. 54, NO. 3, AUGUST 1972 ¨ Most start classic Tennis elbow ¨ Associated with activities of repeated pronation and supination ¨ Tenderness 3 - 4 cm distal and anterior ¨ Middle finger tightens fascial origin of ERCB pinches PIN ¨ Occ Sensory – superficial radial nerve ¨ Slight loss extension ¨ EMG’s not much use
- 40. JBJS-B VOL. 54, NO. 3, AUGUST 1972
- 41. • Passive pronation ERCB indents PIN
- 42. • Arcade of Frohse fibrous band beginning of Superficial portion of supinator
- 43. Radial tunnel Syndrome Treatment Release ERCB Release supinator
- 44. J Shoulder Elbow Surg 2006;15: 367-370 • Painful snapping on flexion and pronation • Vague laterally based pain • Worse with flexion and extension
- 45. Medial epicondylitis (Golfer’s elbow) • Clinical • Pain over medial aspect of the elbow • Ulnar nerve symptoms • Treatment • Non operative- PRP • Surgical release
- 46. Medial epicondylitis (Golfer’s elbow) J Am Acad Orthop Surg 1994;2:1-8
- 47. Ulnar nerve compression (Cubital tunnel) • History • Numbness, weakness, clumsiness • Examination • Sensory • Motor • Tenderness, Tinel sign positive, wasting • Treatment • Conservative • nightsplints • Surgical release Volume 15, Number 11, November 2007
- 48. Ulnar nerve surgery •Decompression, •Medial epicondylectomy •Anterior transposition • Subcutaneous • Intramuscular • Submuscular •Endoscopic decompression
- 49. Hyperextension valgus overload • Laxity/ continued stress on MCL • Olecranon mal-tracks • Posteromedial impingement • Treatment • Re training • Strengthen flexor pronator muscle mass • Athroscopic debridement posteromedial corner • Reconstruct MCL
- 51. Distal biceps rupture • Increasingly recognized • Operative • Non operative • Reasonable with Brachialis • Lose • 15-30 % flexion strength • 30-50% Supination • Fatiguability
- 52. Distal biceps • Radiographs: • Often normal • May show irregularity or bony avulsion • MRI, U/S: • Indicated if Dx in doubt • Partial tear • Delayed presentation • Intact lacertus fibrosus
- 53. Chronic/ Delayed Acutely < 3 weeks
- 54. Arthritic conditions • Rheumatoid Arthritis • Osteoarthritis • Crystal arthropathies • Gout • Pseudogout Traumatic Injuries Fractures Dislocation Ligamentous Injuries
- 55. RED FLAGS • Severe, unremitting pain present at rest and night. • History of cancer • Signs of systemic disease such as weight loss, generalised joint pains, fever, lymphadenopathy • Features such as a mass lesion